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Knock Knees – Can I reverse it? (Part 2)

In the previous entry for Knock Knees, we discuss about the different types of knock knees and the contributing factors of it. Now, we will talk about the problems of this condition and ways we could get rid of it.

The Problems of this condition

The alignment of the knee joint in someone with knock knees is such that there is an increased force on the medial (inner) part of the knee joint. This can predispose the knee joint to osteoarthritis because of the increased loading on the medial compartment.
Symptoms from this may not even present within the knee joint, you may have ankle problems or hip problems as a result of having knock knees.

How do I get rid of it?

External aids:

1. Orthotics

The knee joint may appear to be misaligned if the foot is not biomechanically sound. This means that someone with a very pronated/inverted/flat feet may be at risk of developing a symptoms similar to someone with knock knees. Placing an insole or orthotics device may help correct the foot position, and indirectly the alignment of the knee joint.

2. Knee braces

These can help prompt correct alignment of the knee joint, but may create a degree of dependency.

3. Strengthening

A physiotherapist can design an exercise program to help strengthen weak muscles. By focussing on the specific muscles that require strengthening, you will put your body is a safe healthy direction, and will be able to train for all types of sporting challenges and limit your risk of injury.

4. Stretching

Stretching is an important component of knock knee reversal. When a joint has spent all it’s time in a misaligned position, certain structures will shorten and become stiff. Stiffness in the joints and muscles will make it very difficult to train and strengthen the area. A physiotherapist can assess the position of your knee, ascertain which structures are tight, and give you an appropriate stretching program.

 

Knock Knees – Can I reverse it? (Part 1)

Knock knees is a phenomenon where it appears as though your knees are at an inwards angle in relation to your feet. Most kids under the age of 6 appear to have knock knees, but grow out of it as their body shape changes. An adult with knock knees may or may not have pain – mostly depending on the severity.

In this article, we would discuss on the different types of knock knees and the contributing factors that may develop with this condition. 

When discussing the reasons for knock knees, structure of the bones and joints must be assessed. Structural reasons for knock knees are not normally reversible, unless surgery is indicated. When it comes to the strength, control and stiffness of muscles that control the alignment of the knee, a full assessment must take place so that a corrective program can be enforced.

Structural reasons:

Genu varum: … Not Reversible

A structural deformity of the knee joint, causing the lower leg to be angled inwards and the upper thigh to be angles outwards, causing a bowing effect.

Tibial valgus: … Not Reversible

This is a deformity of the tibia.The bone angles outward towards the end furthest from the knee joint.

Coxa Varum: … Not Reversible

A deformity of the femur; the angle between the head and shaft of the femur is more acute, making the shaft of the femur angle inwards.

Q angle: … Not Reversible

This is the angle between the line of the femur, and the line of the mid patella – tibial tuberosity. A larger Q angle will mean more biomechanical problems within the knee joint.

Poor strength of:

Hip external rotators: … Reversible

• Gemellus inferior & superior
• Obturator internus & externus
• Quadratus femoris
• Piriformis
• Gluteus maximus
• Gluteus medius posterior fibers
• Sartorius

Weakness in these muscles will cause the femur to internally rotate causing an increased ‘knock knee’ effect.

Hip abductors: … Reversible

• Gluteus medius
• Gluteus minimus
• Tensor fasciae latae
• Sartorius

Without the strength of these muscles, the femur is more likely to adduct, increasing the knock knee appearance.

Quadriceps: … Reversible

• Rectus femoris
• Vastus medialis, lateralis & intermedius

Asymmetry in the strength of this muscle group may result in misalignment of the knee joint, giving the appearance of knock knees. Generally it will be the inner most compartment of this muscle that is weak.

Hamstrings: … Reversible

• Biceps Femoris
• Semitendinosis
• Semimembranosis

Similar to the quadriceps, asymmetry in the strength of this muscle group i.e. inner most compartments (semitendinosis and semimembranosis) may lead to this appearance.

Poor control of:

Hip External rotators: … Reversible

Hip abductors: … Reversible

Lumbo/pelvic muscles: … Reversible

If these muscles are not controlled well because they have poor activation or endurance, they muscles will not be able to hold the knee joint in a correct alignment constantly. In other words, the muscles will get tired, and they will not be doing their job.

Stiffness in the:

Hip: … Reversible

Tight muscles in the hip region may limit the range of motion available. If the joint is not moving correctly, the required muscles will not be able to work to correctly align the knee joint.

I have corkie (bruise)? What should I do?

Almost everybody experiences corkies or bruises during his lifetime. Some people are more prone to develop corkies than others. In many cases you don't have to worry about a corkie but it is important to know at which stage you should see a doctor.

What are Corkies?

Corkies are also known as bruise or contusion. They are a type of a relatively minor bleeding (hematoma) of your tissues in which small blood vessels are damaged after a trauma. Bruises can occur at different layers of the body and include skin, deeper tissue, muscles and bones. Most bruises happen after a fall, hitting an object or getting a hit during sports. In many cases it takes a while till you notice a corkie and you will not immediately feel the symptoms right after an incident. Typical areas for corkies are at the front of the thigh, shin, at the frontal pelvic bone (hip pointer or iliac crest) and on your forearms.

How do I know I have a corkie/bruise and what are the symptoms?

A corkie presents with the following symptoms:

• initially short severe pain during trauma (hit, fall as mentioned above)
• later the pain reduces and becomes more of a local tenderness
• swelling (not always)
• bleeding (hematoma- dark blue colored spot on the skin)
• pain during action /use

What are the contributing factors?

The size and shape of a bruise is influenced by several factors such as age, condition- color and type of tissue. Furthermore the location, striking force of a hit or blood disorders (coagulation problems) have an impact on the size and shape of a corkie.

What should I do when I have a corkie?

The treatment of light corkies includes:

• RICE (Rest, Ice, Compression, Elevation) to reduce pain and swelling
• painkillers
• soft stretching after a few days when the pain settled down
• after the inflammatory phase (3-5days) heat to loosen up tight muscles

When should I see a doctor?

You should see a doctor if you have a moderate-severe corkie/bruising. This is indicated if:

• you have severe pain and tenderness
• you develop a massive swelling
• movements of the affected area are very painful
• you have a big corkie without any explanation/reason

Note: If you have unexplained bruises which occur very frequently over a long period of time it is advisable to see a doctor to rule out skin or blood disorders (platelet or coagulation disorder). Furthermore unexplained bruising may also be a warning sign of child abuse, internal bleeding or other serious health problems. The usage of several drugs (e.g. steroids, blood thinners) can cause easier bruising.

How long does it take for the corkie to disappear?

Normally light bruises heal within 2-3 weeks. Depending on the severity and the individual healing process it can take longer. Deeper bruises take more time to heal.

Maybe it’s not Plantarfasciitis but Heel Fat Pad Syndrome

Do you have heel pain? And think it is Plantar Fasciitis?

Maybe not, it might be another type of heel pain called the Heel Fat Pad Syndrome.

What´s the difference between the Plantar Fasciitis and Heel Fat Pad Syndrome?

As shown in the illustration, both structures are in the same area of the heel whereas the plantar fascia (illustrated as plantar apponeurosis) is covered by the fat pad. The plantar fascia attaches at the toes and forms the medial (longitudinal) arch of the foot. It provides static support of the medial arch and dynamic shock absorption. The main functions of the fad pad is shock absorption of stress during heel strike (heel contact during walking).

While both the heel fat pad and plantar fascia can be a source for heel pain, the contributing factors, clinical signs and symptoms and management for them differ.

Plantar Fasciitis

Plantar fasciitis is an overuse condition of the plantar fascia.

Contributing factors: It is often seen in people with foot deformities e.g. flat feet (low arches) or pes cavus (high arches). This deformities can lead to an excessive strain at the fascia during walking and hence cause pain. Other risk factors which can lead to increased stress in the fascia are inappropriate or non-supportive footwear, reduced ankle mobility, obesity and work related weight bearing.

Clinical signs and symptoms: A typical clinical sign is swelling of the plantar fascia and can be confirmed by ultrasound investigations. People with plantar fasciitis classically have a gradual onset of symptoms and feel their pain more on the inner side of the heel. Further symptoms are acute tenderness of the inner side of the heel, a tight plantar fascia and pain during stretching of the fascia. Especially the first steps in the morning or after rest are painful. The pain seems to decrease after a few minutes, and returns as the day proceeds and time on the feet increases.

Management: Due to the tightness of the plantar fascia that leads to pain, treatments involve stretching and massaging to release the tight fascia and calf muscles. Other management include avoiding aggravating activities (e.g. wearing heels), cold therapy (R.I.C.E), anti-inflammatory drugs, taping to to relief pain and lastly it is crucial to strengthen calf muscles that have weakened during the pain process. Some patients who are still symptomatic after conservative treatment might need surgery.

Heel Fat Pad Syndrome

Heel fat pad syndrome is often caused by a decreased elasticity of the fat pad. A fall onto the heel from a height or chronically excessive heel strike with poor footwear can also lead to heel pain.

Contributing factors: Increased age and weight decreases the elasticity of the fat pad.

Clinical signs and symptoms: Compared to plantar fascitis, fat pad related heel pain is felt more at the outer side of the heel especially when the heel gets loaded (heel strike). MRI investigations will reveal changes in the fat pad showing signs of swelling.

Management: Treatments aimed at unloading the heel by avoiding aggravating activities. In an acute situation the R.I.C.E. rule (Rest Ice Compression Elevation) should be applied and anti inflammatory drugs are given. Further treatment includes taping, the use of a silicone gel heel pad and use of appropriate footwear.

References:

1. Brukner, P & Khan, K 2007, Clinical Sports Medicine, 3^rd edition, Tata McGraw Hill, Australia .
2. Cole, C, Seto, G & Gazewood, J 2005, 'Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy`, American Family Physician, vol. 72, no. 11, pp. 2237-42.
3. Thomas, JL, Christensen,, JC, Kravitz,, SR, Mendicino, RW,  Schuberth, JM, Vanore, JV, Weil, LS, Zlotoff, HJ, Bouche, R & Baker, J 2010, ´ The Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline–Revision 2010`,The Journal of Foot & Ankle Surgery, vol. 49, pp. 1-19.

Ankle Overpronation and Injuries video

Have you wondered why overpronation (rolling inward) of your ankles can cause injuries? Click on the video to find out more.

Surgical Procedure of Total Hip Replacement video

Do you have hip osteoarthritis and is so painful that you are considering to have a Total Hip Replacement surgery? Click on the following link to understand more about the surgical procedure of the Total Hip Replacement.

Total Knee Replacement Surgery video

What is exactly happening when you go through a total knee replacement surgery? Click on the following video to have a better understanding about the procedure.

5 questions to ask about your pain

Treatment for musculoskeletal pains involving your joints, bones and muscles are a little different from treatment for a cold or flu. Often resolving the symptoms such as fever is pretty much the same as solving the problem itself e.g. the bugs are getting terminated! We all know that the better we understand our situation, the better we help ourselves. So here are 5 questions you should ask your doctor or therapist treating you using a sprained ankle as an example.

1) Ask for an explanation for your symptoms. This is a relative straight forward question to find out what exactly is hurting. This is not the same as what's causing the pain, which is the next question. Ask, "Why does it hurt at the outside of the ankle and not the inner side of your foot?" Symptoms: Your ankle ligaments have been stretched and are now inflamed. The initial swelling is a result of your body protecting itself and it part of the healing process.

2) Ask for the diagnosis behind the symptoms. Symptoms and diagnosis are two very different things. Symptoms are 'signs' of injury, while diagnosis is about determining the underlying cause of injuries. Unfortunately, the terms symptoms and diagnosis are often used interchangeably. A collection of symptoms are what points to a diagnosis of a condition. Some conditions like ankle sprains are relatively easy to identify as either they have a few simple symptoms and not many conditions share the same overlapping symptoms. But some conditions, like back pain, can be difficult to determine without undergoing a more vigorous process of elimination and hypothesis or critical analysis. The diagnosis here is an lateral ankle sprain, meaning that the ankle was inverted inwards from the outer edge of the foot beyond its limits, stretching one of the ankle ligaments.

3) Ask if the treatment resolves the symptoms or underlying cause. In the case of ankle sprain, the treatments such as cold compress and therapeutic ultra-sound that reduce the swelling and lessen the pain are simply resolving the symptoms – the inflamed ligaments.

After the swelling has gone down and it is no longer painful to move, your ligaments are still stretched and are longer than what they were before. This leads to reduced ankle stability and proprioception, making another ankle sprain happening again that much more likely

If your doctor or therapist packs you off after getting the swelling down, you have not addressed how to prevent an ankle sprain happening again in the near future. You have only treated the symptoms.

What is needed here is to prescribe a solution to compensate for the lax ligaments such as exercises, taping, supports to treat and manage the underlying cause.

4) How long should the treatments last? This is seems like an obvious enough question and is usually asked. But often the patients ask in order to find out when they will be done with the treatment.

You should also ask this question to collaborate what you observe with what the therapist says should be the improvement schedule, validating the diagnosis.

If the therapist says that the swelling should go down by two treatment sessions and it has not after four, the earlier diagnosis might have to be revaluated or you simply could be slow in responding to the treatment. It's just good to know.

5) Understand what you need to do to manage or resolve the underlying causes. Make sure your therapist know what constraints you face. If you have sprained your ankle playing football, you are not likely to follow your therapist's advice to stop playing football. Make sure that your therapist knows about your love of the game and that you intend to continue playing.

Your therapist can then teach you how to tape or brace your ankle before a game and train you with rigorous ankle proprioception and strengthening exercises.

Why Badminton Players Get Tennis Elbow?

• Diffuse pain over lateral elbow just below the lateral epicondyle;
• Reduced grip strength;
• Reduced ability to lift a heavy object; or
• In racquet game players, reduced ability to perform a backhand.
• Some people with tennis elbow also experience tingling sensation or numbness spreading over the forearm and hand.

• Therapeutic ultrasound, heat-retaining braces;
• Soft tissue therapies like deep tissue massage, trigger point treatment, myofacial release;
• Stretching of the tight wrist muscles;
• Specific mobilization techniques combined with gripping exercises;
• Taping, corticosteroids injection, and acupuncture are sometimes helpful;
• Neck and nerve mobilization can also be considered if necessary.

• Focus should be put to achieve good control of the wrist to prevent wrist from functioning at extreme ranges, either into extension or flexion;
• Racquet technique needs to be carefully assessed to correct any technical faults, especially wrist arm control in back hand strokes;
• Encouraging gripping that focuses on hand muscles (the Duck grip), rather than gripping that only focuses on forearms muscles (the Finger grip).

Wrist Sprain – a common wrist injury

Wrist injuries are extremely common injuries. Typically they occur as the result of falling and landing on the wrist as you attempt to break your fall. This causes a traumatic injury to the ligaments and other soft tissues surrounding the wrist.

What is a wrist sprain?

Sprains occur when the wrist ligaments are forcefully stretched into positions beyond their normal limits. A ligament is strong, fibrous tissue or band that limits and controls the motion at a joint. Ligaments around the wrist joint stabilize the position of the hand and allow movement and weight bearing through the upper limb.

Sprains can be considered

Ø     Grade I: Mild injury – wrist ligaments are stretched, no rupture.

Ø     Grade II: Moderate injury – wrist ligaments partially ruptured.

Ø     Grade III: Severe wrist sprain – wrist ligaments are completely ruptured and the wrist may be unstable.

Who is at risk?

Wrist sprains tend to occur after falls. Wet weather may cause slippery surfaces leading to increased numbers of falls. Sprains are also very common in sports such as football, rugby, basketball, skiing, snowboarding, rollerblading etc. The elderly population who are more prone to falls are at greatest risk or serious wrist injuries.

Signs & Symptoms of a wrist sprain?

• Pain with movement of the wrist

• Swelling at or around the wrist joint or into the hand

• Bruising of the skin at wrist or into the hand

• Tenderness over the wrist

• Burning/tingling/pins and needles at the wrist or into the hand

• Reduced function particularly with weight bearing and gripping activities

Diagnosis can be made by piecing together the mechanism of injury to the objective physical findings. There are several other conditions including wrist fractures and or tendonitis which can present similarly to wrist sprains.

An X-ray is important to exclude any possible fracture at the joints. In severe cases an MRI will be useful in determining the extent of ligament soft tissue damage. MRI can also be effective at determining a precise diagnosis if the wrist is failing to heal after the initial diagnosis is made.

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